Cuff configurations for prosthetic heart valve

ABSTRACT

A prosthetic heart valve includes a collapsible and expandable stent having a proximal end, a distal end, an annulus section adjacent the proximal end and an aortic section adjacent the distal end. The stent is formed of a plurality of struts. A cuff is coupled to the stent. The cuff has one or more features configured to reduce abrasion and/or perivalvular leakage.

BACKGROUND OF THE INVENTION

The present invention relates to heart valve replacement and, inparticular, to collapsible prosthetic heart valves. More particularly,the present invention relates to collapsible prosthetic heart valveshaving improved cuff attachments.

Prosthetic heart valves that are collapsible to a relatively smallcircumferential size can be delivered into a patient less invasivelythan valves that are not collapsible. For example, a collapsible valvemay be delivered into a patient via a tube-like delivery apparatus suchas a catheter, a trocar, a laparoscopic instrument, or the like. Thiscollapsibility can avoid the need for a more invasive procedure such asfull open-chest, open-heart surgery.

Collapsible prosthetic heart valves typically take the form of a valvestructure mounted on a stent. There are two types of stents on which thevalve structures are ordinarily mounted: a self-expanding stent and aballoon-expandable stent. To place such valves into a delivery apparatusand ultimately into a patient, the valve must first be collapsed orcrimped to reduce its circumferential size.

When a collapsed prosthetic valve has reached the desired implant sitein the patient (e.g., at or near the annulus of the patient's heartvalve that is to be replaced by the prosthetic valve), the prostheticvalve can be deployed or released from the delivery apparatus andre-expanded to full operating size. For balloon-expandable valves, thisgenerally involves releasing the valve, assuring its proper location,and then expanding a balloon positioned within the valve stent. Forself-expanding valves, on the other hand, the stent automaticallyexpands as the sheath covering the valve is withdrawn.

SUMMARY OF THE INVENTION

In one embodiment, a prosthetic heart valve includes a collapsible andexpandable stent having a proximal end, a distal end, an annulus sectionadjacent the proximal end and an aortic section adjacent the distal end,the stent including a plurality of struts. The heart valve furtherincludes a cuff coupled to a first group of the plurality of strutsadjacent a top edge of the cuff and coupled to a second group of theplurality of struts adjacent a bottom edge of the cuff, the top edgebeing trimmed to closely follow the struts in the first group and thebottom edge being trimmed to closely follow the struts in the secondgroup.

In another embodiment, a prosthetic heart valve includes a collapsibleand expandable stent having a proximal end, a distal end, an annulussection adjacent the proximal end and an aortic section adjacent thedistal end, the stent including a plurality of struts. The heart valvefurther includes a collapsible and expandable valve assembly including acuff and a plurality of leaflets, the plurality of leaflets beingcoupled to the cuff and the cuff being coupled to selected ones of theplurality of struts via a suture, the cuff being wrapped over one of theplurality of struts to form an outer layer and an inner layer.

In another embodiment, a prosthetic heart valve includes a collapsibleand expandable stent having a proximal end, a distal end, an annulussection adjacent the proximal end and an aortic section adjacent thedistal end, the stent including a plurality of struts. The heart valvefurther includes a collapsible and expandable valve assembly including acuff and a plurality of leaflets, and the cuff being coupled to selectedones of the plurality of struts at suture locations, the cuff having afirst thickness in certain regions and a second thickness greater thanthe first thickness in certain other regions.

In another embodiment, a prosthetic heart valve a collapsible andexpandable stent having a proximal end, a distal end, an annulus sectionadjacent the proximal end and an aortic section adjacent the distal end,the stent including a plurality of struts; The heart valve furtherincludes a collapsible and expandable valve assembly including a cuffand a plurality of leaflets, the cuff being coupled to selected ones ofthe plurality of struts, the cuff having a plurality of fibers orientedin a manner to adequately distribute stress substantially uniformlythroughout the cuff.

In yet another embodiment, a method of determining the relative elasticmodulus of a cuff includes applying a predetermined load to the cuff ata location. An amount of deflection of the cuff at the location inresponse to the predetermined load is measured and the relative modulusof elasticity of the cuff is determined based on the predetermined loadand the amount of deflection.

In another embodiment, a prosthetic heart valve includes a collapsibleand expandable stent having a proximal end, a distal end, an annulussection adjacent the proximal end and an aortic section adjacent thedistal end, the stent including a plurality of struts. The heart valvefurther includes a collapsible and expandable valve assembly including acuff and a plurality of leaflets, the cuff being coupled to selectedones of the plurality of struts via a suture, the cuff being formed of aporous material and having microspheres embedded in the porous material,the microspheres being capable of expanding upon contact with blood.

In another embodiment, a prosthetic heart valve includes a collapsibleand expandable stent having a proximal end, a distal end, an annulussection adjacent the proximal end and an aortic section adjacent thedistal end, the stent including a plurality of struts. The heart valvefurther includes a collapsible and expandable valve assembly including acuff and a plurality of leaflets, the cuff being coupled to selectedones of the plurality of struts, the cuff including a first material anda second material, the first material being different from the secondmaterial.

In another embodiment, a prosthetic heart valve for implanting within anative valve annulus includes a collapsible and expandable stent havinga proximal end, a distal end, an annulus section adjacent the proximalend and an aortic section adjacent the distal end, the stent including aplurality of struts. The heart valve further includes a collapsible andexpandable valve assembly including a cuff and a plurality of leaflets,the cuff being coupled to selected ones of the plurality of struts and abuffer including a layer of material coupled to selected regions of thecuff.

In another embodiment, a prosthetic heart valve for implanting within anative valve annulus includes a collapsible and expandable stent havinga proximal end, a distal end, an annulus section adjacent the proximalend and an aortic section adjacent the distal end, the stent including aplurality of struts. The heart valve further includes a collapsible andexpandable valve assembly including a cuff and a plurality of leaflets,the cuff including a first cuff coupled to select ones of the pluralityof struts, the first cuff having extended portions configured to wraparound the proximal end of the stent.

In another embodiment, a prosthetic heart valve for implanting within anative valve annulus includes a collapsible and expandable stent havinga proximal end, a distal end, an annulus section adjacent the proximalend and an aortic section adjacent the distal end, the stent including aplurality of struts and hinges interposed between selected struts. Theheart valve further includes a collapsible and expandable valve assemblyincluding a cuff and a plurality of leaflets, the cuff being coupled toselected ones of the plurality of struts.

BRIEF DESCRIPTION OF THE DRAWINGS

Various embodiments of the presently disclosed heart valves aredisclosed herein with reference to the drawings, wherein:

FIG. 1 is a side elevational view of a conventional prosthetic heartvalve;

FIG. 2 is a highly schematic cross-sectional view taken along line A-Aof FIG. 1 and showing the prosthetic heart valve disposed within anative valve annulus;

FIG. 3A is a developed view of a cuff;

FIG. 3B is a perspective side view of the cuff of FIG. 3A after theattachment portions of the cuff have been coupled together;

FIG. 3C is a schematic view showing an exemplary arrangement forattaching a cuff to a stent;

FIGS. 3D and 3E are enlarged side views showing a portion of a firstvalve having an untrimmed cuff and a portion of a second valve having atrimmed cuff, respectively;

FIGS. 3F and 3G are top views of a valve having an untrimmed cuff and avalve having a trimmed cuff, respectively;

FIGS. 4A and 4B are schematic representations showing the assembly of acuff, a leaflet and struts of a stent;

FIG. 5A is an enlarged elevational view of a cuff coupled to struts, thethickness of the cuff differing from one area to another;

FIG. 5B is a cross-sectional representation of the cuff having a varyingthickness;

FIGS. 5C and 5D are enlarged views showing portions of a cuff havingdifferent fiber orientations;

FIG. 5E is an enlarged partial elevational view showing one possibletechnique of attaching the cuff to the stent based on fiber orientation;

FIG. 5F is a schematic representation of a method of determining therelative elastic modulus of a cuff;

FIG. 5G is a side elevational view of a prosthetic heart valve having anexternal cuff, with a cross-section of the cuff showing microspheresembedded therein;

FIG. 6A is a developed view of a portion of a valve having a cuff with acombination of synthetic portions and tissue portions;

FIGS. 6B-D are schematic representations showing various arrangementsfor coupling a leaflet and cuff to a stent to form a prosthetic heartvalve;

FIGS. 7A and 7B are schematic representations showing the attachment ofa cuff, a leaflet and a buffer to a stent;

FIGS. 7C-G are schematic representations showing various cuff and bufferarrangements;

FIGS. 7H-K are schematic representations showing the attachment of acuff and a buffer to a stent;

FIGS. 8A-D are schematic representations of various examples of pocketsformed between a cuff and a buffer;

FIG. 9A is a schematic representation of a foldable extended cuff;

FIGS. 9B-G are schematic representations of various methods of attachingan extended cuff to a stent;

FIG. 9H is a schematic representation of an extended cuff being foldedto both the inner and outer diameters of a stent;

FIG. 10 is a schematic representation of one possible suture pattern forattaching a buffer to a cuff;

FIG. 11 is a schematic representation of a heart valve including anupper and lower buffer layer; and

FIG. 12 is a schematic representation of a heart valve including anextended cuff and hinges.

Various embodiments of the present invention will now be described withreference to the appended drawings. It is to be appreciated that thesedrawings depict only some embodiments of the invention and are thereforenot to be considered limiting of its scope.

DETAILED DESCRIPTION OF THE INVENTION

Despite the various improvements that have been made to the collapsibleprosthetic heart valve delivery process, conventional devices sufferfrom some shortcomings. For example, with conventional self-expandingvalves, clinical success of the valve is dependent on accuratedeployment and sealing. Inaccurate deployment and anchoring may resultin the leakage of blood between the implanted heart valve and the nativevalve annulus, commonly referred to as perivalvular (“also known asparavalvular”) leakage. In aortic valves, this leakage enables blood toflow from the aorta back into the left ventricle, reducing cardiacefficiency and putting a greater strain on the heart muscle.Additionally, calcification of the aortic valve may affect performanceand the interaction between the implanted valve and the calcified tissueis believed to be relevant to leakage. Additionally, in certainprocedures, collapsible valves may be implanted in a native valveannulus without first resecting the native valve leaflets. To reducethese adverse events, the optimal valve would anchor adequately and sealwithout the need for excessive radial force that could harm nearbyanatomy and physiology.

Moreover, anatomical variations from one patient to another may affectwear and durability of portions of a prosthetic heart valve.Specifically, certain portions of a cuff may wear more quickly thanothers. On the other hand, a thicker cuff may address durabilityconcerns but may unfavorably increase the crimp profile of theprosthetic heart valve, making it difficult to successfully deliver andimplant the device. Moreover, removal of a fully-deployed heart valvefrom the patient may be required if it appears that the valve is notfunctioning properly due to wear. However, removing a fully deployedheart valve increases the risk of infection and/or damage to hearttissue. Thus, methods and devices are desirable that would reduce theneed to remove a prosthetic heart valve from a patient as a result ofcuff wear.

There therefore is a need for further improvements to the devices,systems, and methods of manufacturing collapsible prosthetic heartvalves, and in particular, self-expanding prosthetic heart valves havingcuffs. Among other advantages, the present invention may address one ormore of these needs.

As used herein, the term “proximal,” when used in connection with aprosthetic heart valve, refers to the end of the heart valve closest tothe heart when the heart valve is implanted in a patient, whereas theterm “distal,” when used in connection with a prosthetic heart valve,refers to the end of the heart valve farthest from the heart when theheart valve is implanted in a patient. When used in connection withdevices for delivering a prosthetic heart valve or other medical deviceinto a patient, the terms “trailing” and “leading” are to be taken asrelative to the user of the delivery devices. “Trailing” is to beunderstood as relatively close to the user, and “leading” is to beunderstood as relatively farther away from the user.

FIG. 1 shows one such collapsible stent-supported prosthetic heart valve100 known in the art. The prosthetic heart valve 100 is designed toreplace the function of a native tricuspid, bicuspid or unicuspid valveof a patient, such as a native aortic valve. It should be noted thatwhile the inventions herein are described predominately in connectionwith their use with a prosthetic aortic valve and a stent having a shapeas illustrated in FIG. 1, the inventions may also be used with bicuspidvalves, such as the mitral valve, and with stents having differentshapes, such as those having a flared or conical annulus section, aless-bulbous aortic section, and the like, and a differently shapedtransition section. Examples of collapsible prosthetic heart valves aredescribed in International Patent Application Publication No.WO/2009/042196; U.S. Pat. No. 7,018,406; and U.S. Pat. No. 7,329,278,the disclosures of all of which are hereby incorporated herein byreference.

Prosthetic heart valve 100 will be described in more detail withreference to FIG. 1. Prosthetic heart valve 100 includes expandablestent 102, which may be formed from biocompatible materials that arecapable of self-expansion, such as, for example, shape memory alloyssuch as nitinol. Stent 102 extends from proximal or annulus end 130 to adistal or aortic end 132, and includes annulus section 140 adjacent theproximal end and aortic section 142 adjacent the distal end. Annulussection 140 has a relatively small cross-section in the expandedcondition, while aortic section 142 has a relatively large cross-sectionin the expanded condition. Preferably, annulus section 140 is in theform of a cylinder having a substantially constant diameter along itslength. Transition section 141 may taper outwardly from annulus section140 to aortic section 142. Each of the sections of stent 102 includes aplurality of cells 112 connected to one another in one or more annularrows around the stent. For example, as shown in FIG. 1, annulus section140 may have two annular rows of complete cells 112 and aortic section142 and transition section 141 may each have one or more annular rows ofpartial cells. Cells 112 in aortic section 142 may be larger than thecells in annulus section 140. The larger cells in aortic section 142better enable prosthetic valve 100 to be positioned in the native valveannulus without the stent structure interfering with blood flow to thecoronary arteries.

Stent 102 may include one or more retaining elements 118 at distal end132 thereof, the retaining elements being sized and shaped to cooperatewith female retaining structures (not shown) provided on the deploymentdevice. The engagement of retaining elements 118 with female retainingstructures on the deployment device helps maintain prosthetic heartvalve 100 in assembled relationship with the deployment device,minimizes longitudinal movement of the prosthetic heart valve relativeto the deployment device during unsheathing or resheathing procedures,and helps prevent rotation of the prosthetic heart valve relative to thedeployment device as the deployment device is advanced to the targetlocation and the heart valve deployed. In some variations, retainingelements 118 may be disposed near proximal end 130 of heart valve 100.

Prosthetic heart valve 100 includes valve assembly 104, preferablypositioned in the annulus section 140 of stent 102 and secured to thestent. Valve assembly 104 includes cuff 106 and a plurality of leaflets108, which collectively function as a one-way valve by coapting with oneanother. As a prosthetic aortic valve, valve 100 has three leaflets 108.However, it will be appreciated that other prosthetic heart valves withwhich the leak occluders of the present invention may be used may have agreater or lesser number of leaflets.

Although cuff 106 is shown in FIG. 1 as being disposed on the luminal orinner surface of annulus section 140, it is contemplated that the cuffmay be disposed on the abluminal or outer surface of the annulus sectionor may cover all or part of either or both of the luminal and abluminalsurfaces. Both cuff 106 and leaflets 108 may be wholly or partly formedof any suitable biological material or polymer such as, for example,PTFE.

Leaflets 108 may be attached along their belly portions to cells 112 ofstent 102, with the commissure between adjacent leaflets attached tocommissure features 116. As can be seen in FIG. 1, each commissurefeature 116 may lie at the intersection of four cells 112 of stent 102,two of the cells being adjacent one another in the same annular row, andthe other two cells being in different annular rows and lying inend-to-end relationship. Preferably, commissure features 116 arepositioned entirely within the annulus section 140 of stent 102 or atthe juncture of annulus section 140 and transition section 141.Commissure features 116 may include one or more eyelets which facilitatethe suturing of the leaflet commissure to the stent.

Prosthetic heart valve 100 may be used to replace a native aortic valve,a surgical heart valve, a repair device or a heart valve that hasundergone a surgical procedure. The prosthetic heart valve may bedelivered to the desired site (e.g., near the native aortic annulus)using any suitable delivery device. During delivery, the prostheticheart valve is disposed inside the delivery device in the collapsedcondition. The delivery device may be introduced into a patient using atransfemoral, transapical, transseptal or any other percutaneousapproach. Once the delivery device has reached the target site, the usermay deploy prosthetic heart valve 100. Upon deployment, prosthetic heartvalve 100 expands so that annulus section 140 is in secure engagementwithin the native aortic annulus. When the prosthetic heart valve isproperly positioned inside the heart, it works as a one-way valve,allowing blood to flow from the left ventricle of the heart to theaorta, and preventing blood from flowing in the opposite direction.

FIG. 2 is a highly schematic cross-sectional illustration of prostheticheart valve 100 disposed within native valve annulus 250. As seen in thefigure, the annulus section 140 of stent 102 has a substantiallycircular cross-section which is disposed within the non-circular nativevalve annulus 250. At certain locations around the perimeter of heartvalve 100, crescent-shaped gaps 200 form between the heart valve andnative valve annulus 250. Blood flowing through these gaps and pastvalve assembly 104 of prosthetic heart valve 100 can cause regurgitationand other inefficiencies which reduce cardiac performance. Such improperfitment may be due to suboptimal native valve annulus geometry due, forexample, to calcification of native valve annulus 250 or to unresectednative leaflets.

The following embodiments relate to various configurations that addressdurability and leakage of prosthetic heart valves. Some of theembodiments may be relevant to address durability and crimp profileconcerns while others address leakage around the valve assembly throughthe gaps described above. Still, other embodiments relate toconfigurations of the cuff that address durability, crimp profile andleakage.

FIGS. 3A and 3B illustrate the outer surface of a cuff before couplingto a stent. Cuff 300 includes a body 302, a series of posts 304 a, 304b, 304 c and a pair of attachment portions 306. Attachment portions 306are adapted to be coupled together to form cuff 300 into the wrapped orassembled configuration shown in FIG. 3B. Attachment portions 306 mayoverlap one another and may be coupled together using a suture, anadhesive or any other suitable means. Cuff 300 may be placed in thewrapped configuration either before, during or after being coupled to astent.

FIG. 3C illustrates the coupling of cuff 300 to a portion of stent 102using sutures. Cuff 300 may be coupled to stent 102 by wrapping suturesS1, S2 along certain struts of the stent 102. Cuff 300 may also becoupled to commissure features 116 along posts 304 a, 304 b and 304 c.While FIG. 3C illustrates cuff 300 disposed on the luminal surface ofstent 102, it will be understood that cuff 300 may instead be disposedon the abluminal surface of the stent or on both surfaces. Moreover,while FIG. 3C illustrates the use of two sutures S1, S2 to attach cuff300 to stent 102, it will be understood that a single suture, or three,four, five, or more sutures may also be used to couple the cuff to thestent.

Excess portions of the body 302 of cuff 300 may be trimmed using acutting mandrel, a die or other suitable means. A fixation device may beuseful in this trimming process. One fixation device useful for thispurpose is shown in U.S. Provisional Patent Application Ser. No.61/666,174 entitled “VALVE ASSEMBLY FOR CRIMP PROFILE” filed Jun. 29,2012, the content of which is hereby incorporated by reference in itsentirety. The trimming of cuff 300 may be accomplished either prior toor after the attachment of the cuff to stent 102. The degree to whichexcess portions are trimmed from the cuff may affect the valve'sperformance as will be appreciated from the following series ofdrawings.

By way of comparison, FIGS. 3D and 3E are partial enlarged drawings of afirst stent-cuff assembly that has been coupled without a fixationdevice and a second stent-cuff assembly that has been coupled using afixation device, respectively. As seen in FIG. 3D, with cuff 300 coupledto stent 102, the cuff has excess portions 312. Conversely, in FIG. 3E,cuff 300 is coupled to stent 102, but the excess portions 312 have beentrimmed away with the aid of a fixation device so that the upper edge ofthe cuff aligns with struts 314 of the stent. The upper edge 320 of cuff300 may closely follow struts 314 a, 314 b, 314 c, 314 d of stent 102,the upper edge being substantially aligned with the struts.Alternatively, the upper edge 320 of cuff 300 may track the neareststrut, being disposed about 0.5 inches to about 2.0 inches from thenearest strut. With cuff 300 attached to stent 102, leaflets (not shown)may be attached to the cuff to complete the valve assembly.

FIG. 3F illustrates an end view of cuff 300 coupled to stent 102. Asseen in FIG. 3F, excess portions 312 of cuff 300 have formed a loosesegment 330. Loose segment 330 may lead to cuff billowing when the valveis implanted in vivo. In contrast, FIG. 3G illustrates a cuff-stentassembly in which cuff 300 has been trimmed using a fixation device asdescribed above. As seen in FIG. 3G, cuff 300 does not have any loosesegments, and is therefore less prone to billowing or swelling.Sufficient tension between the cuff and the stent may provide forsuperior prosthetic heart valve performance.

FIG. 4A illustrates one method of coupling a cuff 450 to the struts of astent. Cuff 450 may be coupled to the stent via a single suture or aplurality of sutures. The method illustrated in FIG. 4A utilizes threesuture wraps W1, W2, W3 to couple cuff 450 to struts 414 a, 414 b andleaflet 420. The cuff 450 may be folded over strut 414 a and a firstsuture W1 may wrap around the top of cuff 450, pierce through an outerlayer 450 a of the cuff, run under strut 414 a and then pierce throughinner layer 450 b of the same cuff, thereby attaching the two layers 450a, 450 b of the cuff to strut 414 a. A second suture W2 may piercethrough two layers of leaflet 420, the inner layer 450 b of the cuff,the outer layer 450 a of the cuff and loop back around, piercing throughthe inner layer 450 b of the cuff again near a midportion of the cuff,thereby attaching leaflet 420 to the two layers of the cuff. A thirdsuture W3 may pierce through inner layer 450 b, wrap around second strut414 b, and pierce inner layer 450 b a second time to create a loop,coupling inner layer 450 b of the cuff to strut 414 b. Thisconfiguration may help to protect leaflet 420 from strut 414 a.

FIG. 4B illustrates a second method of coupling a cuff 450 to the strutsof a stent. The method illustrated in FIG. 4B also utilizes three suturewraps W1′, W2′, W3′ to couple cuff 450 to struts 414 a, 414 b andleaflet 420. The cuff 450 may be folded over strut 414 a and a firstsuture W1′ may pierce through two layers of leaflet 420, the inner layer450 b of the cuff, the outer layer 450 a of the cuff and return towardthe interior of the valve by piercing both the outer layer 450 a and theinner layer 450 b a second time. A second suture W2′ may pierce throughthe inner layer 450 b and outer layer 450 a of the cuff in a firstdirection near the midpoint of the cuff, and then loop back around,piercing through the outer layer 450 a and the inner layer 450 b in theopposite direction. A third suture W3′ may pierce through inner layer450 b, wrap around second strut 414 b, and pierce inner layer 450 b asecond time to create a loop, coupling inner layer 450 b to strut 414 bas in the first method. It will be understood that variations of thesesuture patterns are possible and that combinations of the differentsuture wraps of FIGS. 4A and 4B may also be desirable.

In addition to trimming away excess portions of the cuff and using novelsuture patterns to improve valve performance, the thickness of the cuffmay also be tailored to provide superior heart valve performance. Inthat regard, a thinning process may be used to create a cuff that has avarying or non-uniform thickness. For example, thinning may beaccomplished by cryocutting, ultrasonic cutting, laser ablation andother known techniques. The same technique used to cut the edges of thecuff may be used to control the cuff thickness. FIG. 5A illustrates acuff 550 coupled to struts 514, the thickness of the cuff beingdifferent in some areas than in others. Specifically, thicker portionsof cuff 550, as marked by arrows “T”, may coincide with suture locationsor high stress areas of interest. Cuff 550 may also have areas ofreduced thickness to help reduce the crimp profile of the valve. Thethickness of cuff 550 may vary so that a technician or user is able toalign the cuff with struts 514 by examining the cuff visually. Cuff 550may also be thickened near the commissure feature attachments as well asnear cuff-leaflet junctions (not shown).

FIG. 5B illustrates a partial cross-section of cuff 550. As seen in FIG.5B, cuff 550 may have a variety of thicknesses, with thicker areas suchas t1 and t3 being more suitable for suturing and greater load bearing,and thinner areas such as t2 having a smaller profile and moreflexibility.

The material of a cuff may also be selected to achieve different goals.In at least some examples, the cuff may be made of a synthetic materialsuch as polyester or ultra high molecular weight polyethylene (UHMWPE)or a suitable combination. Such synthetic materials may enable a thinnercuff to be produced, resulting in a lower crimp profile as well as theneed for less force for loading and resheathing. The use of syntheticmaterials may also increase the durability and life expectancy of thecuff. Fabric and other synthetic materials may further provide adequatebiological responses, such as in-growth to reduce PV-leak.Alternatively, the cuff may be formed from natural materials, includingporcine, bovine, equine, ovine and kangaroo tissue. Such naturalmaterials may provide acceptable operation and good biologicalresponses.

When natural materials are used to form a cuff (e.g., tissue cuffs), thetissue may be oriented in different ways to improve performance. Forexample, the orientation of tissue fibers may be characterized ascircumferential, axial or random and these orientations may be employedin various ways to improve durability or manufacturability, or toprovide a number of other benefits. FIGS. 5C and 5D illustrate twotissue portions used for forming a cuff. FIG. 5C illustrates tissueportion 550C in which the tissue fibers 560C are predominantly orientedin a substantially longitudinal direction, i.e., a direction that, whenthe cuff is assembled to a prosthetic valve, is substantially parallelto the longitudinal axis of the valve. FIG. 5D illustrates tissueportion 550D in which the tissue fibers 560D are predominantly orienteddiagonally, i.e., in a direction that is oblique to the longitudinalaxis of the prosthetic valve when the cuff is assembled therein. In someexamples, tissue fibers 560D may be oriented at a 45 degree angle.Various methods, such as polarized light microscopy, deflection testingand/or tensioning, may be used to determine the dominant tissue fiberorientation. Having characterized the tissue, the cuff may be cut orformed in a manner to best distribute stresses more uniformly throughoutthe cuff, thus helping to increase the strength and durability of thecuff.

FIG. 5E is a partial view of a valve assembly having a cuff 550E coupledto struts 514. Tissue fibers 560 may be oriented predominantly in afirst direction in a first area 580 of the cuff and tissue fibers 560′may be oriented predominantly in a second direction in a second area 582of the cuff. Specifically, as seen in FIG. 5E, the first area 580includes a substantially diagonal orientation of tissue fibers 560 whilethe second area 582 includes a substantially circumferential orientationof tissue fibers 560′. Thus, cuff 550E may be cut and assembled in amanner such that the dominant fiber orientation is in a certaindirection or cuff 550E may be formed of multiple pieces of tissueconnected together, with each piece being selected to have a specificfiber orientation.

In addition to fiber orientation, the relative elastic modulus of atissue sample may be examined to determine the suitability of the tissuefor use in producing a cuff. One method of calculating the relativeelastic modulus will be described with reference to FIG. 5F. Apredetermined load 590 may be applied to a tissue sample 592 in thedirection of arrow F at one or more locations and the amount ofdeflection of the tissue sample in response to the load may be measured.The relative modulus of elasticity of the sample may then be calculatedbased on the amount of deflection and the load. A tissue sample 592 thusmay be accepted or rejected based on the calculated modulus or theminimum-maximum deflection of the sample. In at least some examples, thedeflection of an acceptable tissue sample 592 is between about 1.0 mmand about 7.0 mm at a load that is physiologically relevant andnon-destructive. In at least some other examples, the deflection of anacceptable tissue sample 592 is between about 2.0 mm and about 5.5 mm.

Additional features may be added to the cuff to aid in perivalvularleakage. For example, one method of minimizing perivalvular leakage isto incorporate polyvinyl alcohol (PVA), foam shape memory portions, or asponge-like portion into the material of the cuff. FIG. 5G illustrates aprosthetic heart valve 100G having a stent 102 to which an external cuff506G is coupled. External cuff 506G may be formed from a porous membrane594 embedded with microspheres 595. In one example, microspheres 595 maybe formed of a dry polyvinyl alcohol sodium acrylate. The individualpores of membrane 594 may be smaller than the microspheres 595 so thatthe microspheres are retained, but large enough to allow liquid (e.g.,blood) to travel therethrough. An optional protective layer 596 mayoverlie membrane 594 during shipping and storage of hydrated tissuevalves, but may be omitted for dry valves. As cuff 506G contacts bloodupon the implantation of prosthetic heart valve 100G, microspheres 595may swell in size, increasing the size and specifically the diameter ofthe cuff. The enlarged cuff thus fills the gaps between the native valveannulus and the prosthetic heart valve, minimizing or preventingperivalvular leakage.

In addition to reducing perivalvular leakage, polyvinyl alcohol (PVA)granules may be added to the cuff and/or the leaflets in prostheticheart valves featuring all dry components (e.g., dry tissue technologyor all fabric cuff/leaflet designs) instead of a storage solution.Prosthetic heart valves having PVA granules may be stored, shipped andloaded into a delivery device dry without activating the PVA. The PVAwill be activated when the valve contacts blood upon deployment. Such atechnique may be considered advantageous over other techniques which usea storage solution as the storage solution may prematurely activate thePVA, thereby reducing its effectiveness in mitigating valve leakage atimplantation.

In addition to using entirely natural materials or entirely syntheticmaterials, the cuff may be formed from a combination of natural andsynthetic materials. FIG. 6A illustrates an example of a fabric-tissuecombination cuff 650. In one arrangement, cuff 650 may include bands orstrips of synthetic fabric 620 coupled to a base tissue material 610.Fabric 620 may be woven to tissue material 610 and/or stent 602 and mayincrease the strength of cuff 650 and help distribute the load evenlyacross the valve assembly. In an alternate arrangement, cuff 650 may beformed of alternating portions of natural and synthetic materials. Thecombination cuff may also be formed with the two materials reversed(e.g., a base of fabric overlaid with strips of tissue). By combiningtissue and fabric, the crimping profile and rigidity of the cuff may beadjusted as desired. In at least some other examples, a single cell, arow of cells or other desired grouping of cells may include naturalmaterial, synthetic materials or a combination of both.

FIGS. 6B-D illustrate various configurations for coupling a leaflet anda cuff to a stent to form a prosthetic heart valve. FIG. 6B illustratesthe use of a single-layer cuff. In this configuration of prostheticheart valve 600B, a cuff 650B may be coupled to struts 614 on theluminal surface of stent 602, with leaflet 620 being coupled to cuff650B.

FIG. 6C illustrates a prosthetic heart valve 600C having a cuffincluding a first layer 650C and a second layer 650C′. The first layer650C may be coupled to the abluminal surface of stent 602 and may bemade of tissue or a fabric. The second layer 650C′ may be coupled to theluminal surface of stent 602, the stent effectively being sandwichedbetween the two layers 650C, 650C′. The second layer 650C′ may be formedof the same or a different material than the first layer 650C. Leaflet620 may be coupled to the second layer 650C′ as seen in FIG. 6C.

FIG. 6D illustrates a second variation of a prosthetic heart valve 600Dhaving a cuff including a first layer 650D and a second layer 650D′. Inthis example, both cuff layers 650D, 650D′ are disposed on the luminalsurface of stent 602, the first layer 650D being coupled to the stentand the second layer 650D′ being coupled to the first layer 650D. Thefirst layer 650D and the second layer 650D′ may be formed of the same ordifferent materials. Leaflet 620 may be coupled to the second layer650D′. It will be understood that various techniques may be used tocouple the layers 650D, 650D′ to one another or to stent 602. Forexample, sutures, staples, an adhesive, ultrasonic welding and the likemay be used to couple or bond the layers of the cuff together. Thus, theinclusion of a second layer in the cuff may improve performance andincrease the durability of the cuff.

In another embodiment, instead of forming the cuff with two layers, abuffer material may be disposed over a portion of the cuff. As seen inFIG. 7A, a prosthetic heart valve 700 may include a stent 702 and a cuff750 disposed over a portion of the stent. Cuff 750 may include any ofthe materials discussed above, such as fabric or other syntheticmaterials, or natural materials, such as tissue, and may extend betweena first edge 752 at the outflow end of the cuff and a second edge 754substantially aligned with the bottom of stent 702. A buffer layer 760disposed over a portion of cuff 750 may be coupled to the cuff. In orderto reduce crimp profile, buffer 760 may align with the first edge 752 ofcuff 750 as shown in FIG. 7A and extend over only a portion of the cuff(e.g., buffer 760 may terminate prior to the second edge 754 of thecuff).

Buffer 760 may be made of a non-porous, non-abrasive material such as,for example, thin porcine pericardium. In at least some examples, buffer760 is non-load bearing and the material may be selected to be thin andlubricious with minimal to no porosity. Examples of materials from whichbuffer 760 may be formed include thin porcine pericardium, ultra-highmolecular weight polyethylene (UHMWPE), polytetrafluoroethylene (PTE)membrane or other suitable polymers. Additionally, buffer 760 may bemade of a fiber material having a hydrophilic coating to offer increasedlubricity, for example, to reduce the forces required to load orresheath the prosthetic heart valve. The hydrophilic coating may alsohelp mitigate perivalvular leakage. Specifically, after implantation,the hydrophilic coating may participate in dynamic hydrogen bondingafter contact with blood, thus forming additional material volume aroundthe fibers to help reduce the potential for leakage. Leaflets 720 may beattached to cuff 750, to buffer 760 or to both cuff 750 and buffer 760in region A1. As seen in FIG. 7B, when leaflet 720 opens under pressurein the direction of arrow L1, it may press against buffer 760 instead ofcuff 750, thereby reducing the risk of abrasion to both the cuff andleaflet. Attachment techniques for coupling the cuff to the buffer willbe described in greater detail below.

FIG. 7C illustrates one possible configuration of the buffer. In thisconfiguration, buffer 760C may follow the contours of cuff 750 near thefirst edge 752 of the cuff and form a parabolic pattern 764 halfwaybetween the first edge 752 and the second edge 754 of the cuff.Parabolic pattern 764 may follow the contours of the attachment of aleaflet belly (not shown) to the cuff. Buffer 760C may be first coupledto cuff 750 and the parabolic pattern 764 of the buffer may serve as aguide for attaching the leaflet belly to the cuff to provide arepeatable attachment, thereby improving valve function. As illustrated,buffer 760C is formed of a single piece of natural or syntheticmaterial. It will be understood, however, that the buffer may be formedof multiple pieces of natural or synthetic materials connected to oneanother.

FIG. 7D illustrates a cuff-buffer assembly in which the buffer is formedof multiple pieces of fabric. Each segment 760D of the buffer may followat least a portion of the first edge 752 of cuff 750 and may include oneor more peaks 768 disposed adjacent commissure features (not shown) andbetween a plurality of valleys 767. Each segment 760D of the buffer mayinclude a generally W-shaped profile including three peaks 768A, 768B,768C and two valleys 767. The use of multiple buffer segments 760D,760D′, etc. may serve to further reduce the material used in theprosthetic heart valve and thus reduce the overall crimp profile of theassembled device.

FIGS. 7E and 7F illustrate two more configurations of buffer. In FIG.7E, buffer 760E includes three peaks 768A′, 768B′, 768C′ that are all ofthe same height. In this example, the two end peaks 768A′, 768C′ do notextend all the way up toward the commissure feature, but terminate atthe same height as middle peak 768B′. In FIG. 7F, buffer 760F is similarto that of FIG. 7E, but includes additional flaring portions 769A, 769Bconnected to peaks 768A′ and 768C′ to provide additional leakagemitigation.

The attachment of a buffer to cuff 750 and/or select struts of the stentmay depend on the shape and profile of the buffer. One example of suchan attachment is shown in FIG. 7G, which shows an exemplary attachmentof a segment 760D of the buffer of FIG. 7D. Buffer segment 760D may besutured along first edge 752 of cuff 750 with the same sutures 7S thatattach the cuff to the struts 714 of stent 702. The bottom edge ofbuffer segment 760D may be attached to cuff 750, struts 714, and/or avalve leaflet (not shown) via the sutures 7S′ that attach the leafletbelly to the cuff.

FIGS. 7H-K illustrate several configurations for suturing a cuff and abuffer to struts 714. Specifically, these figures illustrate severalconfigurations of the sutures 7S along first edge 752 shown in FIG. 7G.

In one configuration shown in FIG. 7H, suture 7SH runs from the outerdiameter OD of the assembly, over strut 714, and through cuff 750H andbuffer 760H to the inner diameter ID, and then from the inner diameterback through buffer 760H and cuff 750H to the outer diameter whilepassing under strut 714.

In another configuration shown in FIG. 7I, the upper edges of cuff 750Iand buffer 760I are bent over strut 714 and suture 7SI is passed fromthe outer diameter OD over both upper edges and strut 714 to the innerdiameter ID, and then from the inner diameter back through buffer 760Iand cuff 750I to the outer diameter at a position below strut 714.

In FIG. 7J, cuff 750J is doubled over itself at the axial location ofstrut 714 and suture 7SJ is passed from the outer diameter OD over strut714 and both layers of cuff 750J, through buffer 760J to the innerdiameter ID, and then from the inner diameter back through buffer 760Jand cuff 750J to the outer diameter at a position below strut 714.

In yet another configuration shown in FIG. 7K, cuff 750K may be doubledover itself as in FIG. 7J, but buffer 760K may be bent over the cuff asshown. Suture 7SK may be passed from the outer diameter OD over strut714, the two layers of cuff 750K and the top of buffer 760K to the innerdiameter ID, and then from the inner diameter back through buffer 760Kand cuff 750K to the outer diameter at a position below strut 714. Itwill be understood that these configurations are merely exemplary andthat other configurations or combinations of these arrangements arepossible.

Through various assembly and suturing techniques, a buffer may be usedto form pockets that aid in leakage prevention. FIG. 8A illustrates anassembly similar to that shown in FIG. 7G. In this embodiment, a cuff850 extending between a first edge 852 and a second edge 854 is coupledto a buffer 860 and to a plurality of struts 814 forming a stent 802.One segment of buffer 860 may be sutured along certain struts 814 toform a pocket 870A. Specifically, pocket 870A may be formed by suturing,or otherwise coupling, the segment of buffer 860 along portions of fourstruts using stitch patterns 872A, 872B, 872C, 872E and to cuff 850along contour 872D. Pocket 870A may be filled with a liquid, a gel, apowder or other media to help mitigate perivalvular leakage. One exampleof the filler media may be a solution of PVA sodium acrylate copolymers.Other filler media may include mechanical levers or springs,cantilevered stent component from struts or other material for helpingprovide a bulging of pockets 870A.

The pocket between the buffer and the cuff may be formed in a variety ofshapes. For example, instead of pocket 870A shown in FIG. 8A, the pocketmay be trapezoidal and span over portions of two cells 812. As shown inFIG. 8B, a trapezoidal pocket 870B may span a half of two adjacent cells812. Alternatively, triangular pockets 870C or 870D may be formed asshown and occupy a portion (e.g., a half) of a single cell 812. Pockets870A, 870B, 870C, 870D may follow certain struts 814 and may be formedby suturing buffer 860 to the cuff to create the desired shape. As shownin FIGS. 8C and 8D, the pockets may further take the shape of flowers870E, which may be centered below posts 804 of cuff 850 (FIG. 8C),lemniscate 870F or figure-eights 870G (FIG. 8D). Regardless of theirparticular shape, the pockets, when filled, form thickened regions ofthe prosthetic valve cuff when implanted which help seal the valve inthe native valve annulus, and thereby help to alleviate perivalvularleakage. As noted above, these pockets may include filler media thatdoes not increase the bulk of the heart valve until implantation.

In addition to or instead of being formed near the outflow end of thevalve assembly, the pockets may be formed near the inflow end of anaortic valve. Such pockets may be used to mitigate perivalvular leakagein susceptible areas near the inflow end 954 of the valve. FIG. 9Aillustrates three different examples of forming pockets near inflow end954. In a first example, triangular portions 901 of cuff 950 may extendbeyond inflow end 954. These triangular portions 901 may be folded atlateral line X1 in the direction of arrows F to overlie the remainder ofcuff 950, and may be sewn to the cuff and/or stent struts 914 withsuture pattern 9S to form triangular pockets 908. In a second example,substantially diamond-shaped portions 904 of cuff 950 may extend beyondinflow end 954. These partial diamond-shaped portions 904 may be foldedat lateral line X1 in the direction of arrows F′ to overlie theremainder of cuff 950 within a cell 912, and may be sewn to the cuffand/or stent struts 914 with suture pattern 9S′ to form substantiallydiamond-shaped pockets 910. It will be understood that in somevariations, full diamonds, half diamonds or any portion of a diamond maybe used to form pockets with the cuff. In a third example, a rectangularportion 906 of cuff 950 may extend beyond inflow end 954. Rectangularportion 906 may be folded at lateral line X1 in the direction of arrowF″ to overlie the remainder of cuff 950 in an area occupying a number ofpartial cells 912, and may be sewn to the cuff and/or stent struts 914with suture pattern 9S″ to form rectangular pockets 916.

Triangular pockets 908, substantially diamond-shaped pockets 910 andrectangular pockets 916 may be filled with any suitable filler materialas discussed above with reference to FIG. 8A. Moreover, by using pockets908, 910 and/or 916 instead of an additional cuff layer, the crimpprofile of the resulting prosthetic heart valve may be reduced. It willbe understood that any combination of the pocket shapes described above,or any other pocket shapes, may be used to help mitigate perivalvularleakage, and that the pockets may alternate between shapes, for example,between triangular and rectangular pocket shapes, around the peripheryof cuff 950. It will also be understood that instead of extending cuff950 beyond the inflow end 954 of the valve, a discrete buffer materialmay be sewn to the cuff near inflow end 954 to create the pocketsdescribed above.

Pockets may be created in various shapes at the inflow end 954 of theaortic valve as described above, and may be attached to cuff 950 and/orstent struts 914 in a variety of configurations, illustrated in FIGS.9B-G. In a first example, cuff 950 may be disposed on the outer diameterOD of stent 902, and edge 950B of cuff 950 may be folded under the endof the stent to the inner diameter ID (FIG. 9B). In a second example,cuff 950 may be disposed on the inner diameter ID of stent 902, and edge950C of cuff 950 may be folded under the end of the stent to the outerdiameter OD (FIG. 9C). In a third example, cuff 950 may be disposed onthe outer diameter OD of stent 902 and edge 950D of cuff 950 may befolded over the rest of the cuff on the outer diameter OD (FIG. 9D). Ina fourth example, cuff 950 may be disposed on the inner diameter ID ofstent 902, and edge 950E of cuff 950 may be folded over the rest of thecuff on the inner diameter ID (FIG. 9E). In each of the foregoingexamples, the folded edge of the cuff may be secured to the remainingportion of the cuff and/or to the struts of stent 902 by suturing or inother ways known in the art.

In two other configurations shown in FIGS. 9F and 9G, the cuff is foldedto both inner diameter ID and outer diameter OD. FIG. 9F illustratescuff 950 disposed on the outer diameter OD of stent 902. Portions 950F′of cuff 950 may be folded under the end of stent 902 to the innerdiameter ID, while other portions 950F of the cuff may be folded overthe remainder of the cuff on the outer diameter OD. FIG. 9F illustratesthe opposite configuration in which cuff 950 is disposed on the innerdiameter ID of stent 902. Portions 950G of cuff 950 may be folded underthe end of stent 902 to the outer diameter OD, while other portions950G′ of the cuff may be folded over the remainder of the cuff on theinner diameter ID.

FIG. 9H illustrates a cuff 950H having portions folded to both the innerand outer diameters. Triangular portions 901 of cuff 950H may be foldedin the direction of arrows F1 toward the outer diameter of stent 902,while substantially diamond-shaped portions 904 of the cuff may befolded in the direction of arrows F2 toward the inner diameter of thestent.

Another technique to reduce the crimp profile of a prosthetic heartvalve is to reduce the number of suture wraps that attach the cuff tostruts of the stent. Reference will be made to FIG. 10 to illustratethis reduction in suture usage. As shown, prosthetic heart valve 1000includes a cuff 1050 coupled to struts 1014 of stent 1002. Leaflets 1008are attached to stent 1002 at least via commissure features 1016. Undernormal operation of heart valve 1000, certain struts experience lowerstress than others. Specifically, areas of low stress are outlined byregions LS. To reduce the overall crimp profile of the valve, fewersutures may be used in these areas than in others. For example, cuff1050 may be attached to each strut 1014 by six suture wraps in all areasexcept the designated low-stress areas, in which four suture wraps maybe used. Thus, any number of suture wraps may be used to attach the cuffto any strut and fewer suture wraps may be used in the designatedlow-stress regions LS.

Another mechanism for mitigating perivalvular leakage is to provide theprosthetic heart valve with multiple cuffs. As shown in FIG. 11, heartvalve 1100 may include a pair of cuffs 1150A, 1150B attached to struts1114 of stent 1102. First cuff 1150A may be attached to stent 1102 nearcommissure features 1116 and the outflow edge 1122 of the valveassembly, and may form pockets 1170 similar to those described withreference to FIGS. 7A-8A. Second cuff 1150B may be attached to stent1102 near the inflow end 1102 of the valve assembly, and may extendbeyond the inflow end by triangular portions 1152, which fold up in thedirection of arrows F on either the inner diameter or outer diameter ofthe valve assembly. First cuff 1150A and second cuff 1150B may beattached to one another by suturing or other suitable means at seam1175. These cuffs may be formed from any of the cuff materials describedabove (e.g., natural materials or synthetic materials). First and secondcuffs 1150A, 1150B may be formed from the same material or fromdifferent materials. For example, first cuff 1150A may be formed fromporcine tissue while second cuff 1150B may be formed from a syntheticfabric, or vice versa.

To offset any possible increase in crimp profile, certain features maybe added to the prosthetic heart valve to facilitate delivery. FIG. 12illustrates prosthetic heart valve 1200 having cuff 1250 and leaflets1208 attached to stent 1202 at select struts 1214 and commissurefeatures 1216. Cuff 1250 may include additional triangular portions 1252that may be folded up in the direction of arrows F as described above.To aid in delivery, stent 1202 may include hinges 1270 at the midsectionof the lowermost row of cells 1212 so that the stent may slightly bendat this position during delivery. Similar hinges 1272 may be added at alevel above commissures 1216 to provide additional flexibility to thestent 1202.

Although the invention herein has been described with reference toparticular embodiments, it is to be understood that these embodimentsare merely illustrative of the principles and applications of thepresent invention. It is therefore to be understood that numerousmodifications may be made to the illustrative embodiments and that otherarrangements may be devised without departing from the spirit and scopeof the present invention as defined by the appended claims.

It will be appreciated that the various dependent claims and thefeatures set forth therein can be combined in different ways thanpresented in the initial claims. It will also be appreciated that thefeatures described in connection with individual embodiments may beshared with others of the described embodiments.

The invention claimed is:
 1. A prosthetic heart valve, comprising: acollapsible and expandable stent having a proximal end, a distal end, anannulus section adjacent the proximal end and an aortic section adjacentthe distal end, the stent including a plurality of struts; and acollapsible and expandable valve assembly including a cuff and aplurality of leaflets, the cuff being coupled to selected ones of theplurality of struts, the cuff having a plurality of fibers oriented in amanner to adequately distribute stress substantially uniformlythroughout the cuff.
 2. The prosthetic heart valve of claim 1, whereinthe cuff includes multiple portions, a first group of the portionshaving a first fiber orientation and a second group of the portionshaving a second fiber orientation different from the first fiberorientation.
 3. A prosthetic heart valve for implanting within a nativevalve annulus, comprising: a collapsible and expandable stent having aproximal end, a distal end, an annulus section adjacent the proximal endand an aortic section adjacent the distal end, the stent including aplurality of struts; a collapsible and expandable valve assemblyincluding a cuff and a plurality of leaflets, the cuff being coupled toselected ones of the plurality of struts; and a buffer including a layerof material coupled to selected regions of the cuff, the bufferincluding a plurality of discrete portions.
 4. The prosthetic heartvalve of claim 3, wherein the buffer comprises a thin and lubriciousmaterial.
 5. The prosthetic heart valve of claim 3, wherein the cuffincludes a top edge, and the buffer includes a web of material extendingaround the circumference of the prosthetic heart valve and following thetop edge of the cuff.
 6. The prosthetic heart valve of claim 3, whereinthe stent includes a plurality of commissure features for coupling theplurality of leaflets to the stent and the plurality of discreteportions include a plurality of peaks extending toward the commissurefeatures.
 7. The prosthetic heart valve of claim 3, wherein each of theplurality of discrete portions is coupled to the cuff to form a pockettherebetween.
 8. The prosthetic heart valve of claim 7, wherein thepockets include a filler material.
 9. The prosthetic heart valve ofclaim 8, wherein the filler material includes PVA sodium acrylatecopolymers.
 10. A prosthetic heart valve for implanting within a nativevalve annulus, comprising: a collapsible and expandable stent having aproximal end, a distal end, an annulus section adjacent the proximal endand an aortic section adjacent the distal end, the stent including aplurality of struts; and a collapsible and expandable valve assemblyincluding a cuff and a plurality of leaflets, the cuff including a firstcuff coupled to select ones of the plurality of struts, the first cuffhaving extended portions configured to wrap around the proximal end ofthe stent, the extended portions including portions having at least oneof a triangular or a substantially diamond shape.
 11. The prostheticheart valve of claim 10, further comprising a second cuff coupled to thefirst cuff, the first cuff having a plurality of pockets.
 12. Aprosthetic heart valve for implanting within a native valve annulus,comprising: a collapsible and expandable stent having a proximal end, adistal end, an annulus section adjacent the proximal end and an aorticsection adjacent the distal end, the stent including a plurality ofstruts; and a collapsible and expandable valve assembly including a cuffand a plurality of leaflets, the cuff including a first cuff coupled toselect ones of the plurality of struts, the first cuff having extendedportions configured to wrap around the proximal end of the stent,wherein the extended portions include first portions folded to an innerdiameter of the stent and second portions folded to an outer diameter ofthe stent.